<div class="col-md-9">
  <!-- random product -->
  <div class="span12">
	<div class="outer-border nav-page-sidebar-p10">
	  <div class="nav-judul bg-texture">
		<span class="judul-sidebar">
		  Konfirmasi Pembayaran
		</span>
	  <div class="clearfix"></div>
	  </div>

	  <div class="nav-page-kanan">
		  <form class="form-horizontal" role="form" method="post" action="konfirm.aspx" onsubmit="return gsValidate('kode|nominal|nama_bank|no_rek|nama|bank','ID Order Harus Diisi|Nominal Harus Diisi|Nama Bank Harus Diisi|Nomer Rekening Harus Diisi|Nama Pemilik Harus Diisi|Bank Tujuan Harus Dipilih','required|required_numeric|required|required|required|required');">
			  <div class="form-group">
				<label class="col-lg-3 control-label small">ID Order</label>
				<div class="col-lg-7">
				  <input type="text" class="form-control input-sm" name="kode" placeholder="ID Order" id="kode" maxlength="15">
				</div>
			  </div>
			  <div class="form-group">
				<label class="col-lg-3 control-label small">Nominal</label>
				<div class="col-lg-7">
				   <input type="text" class="form-control input-sm" name="nominal" placeholder="Nominal" id="nominal" maxlength="11">
				</div>
			  </div>
			  <div class="form-group">
				<label class="col-lg-3 control-label small">Nama Bank</label>
				<div class="col-lg-7">
				  <input type="text" class="form-control input-sm" name="nama_bank" placeholder="Nama Bank" id="nama_bank" maxlength="30">
				</div>
			  </div>
			  <div class="form-group">
				<label class="col-lg-3 control-label small">Nomer Rekening</label>
				<div class="col-lg-7">
				  <input type="text" class="form-control input-sm" name="no_rek" placeholder="Nomer Rekening" id="no_rek" maxlength="30">
				</div>
			  </div>
			  <div class="form-group">
				<label class="col-lg-3 control-label small">Nama Pemilik</label>
				<div class="col-lg-7">
				 <input type="text" class="form-control input-sm" name="nama" placeholder="Nama Pemilik" id="nama" maxlength="50">
				</div>
			  </div>
			  <div class="form-group">
				<label class="col-lg-3 control-label small">Bank Tujuan</label>
				<div class="col-lg-7">
				  <select class="form-control input-sm" name="bank" id="bank">
					<option value=""> - - Pilih Bank Tujuan - - </option>
					<?php
						$bank  = $koneksi->query("select * from bank");
						while($row = $bank->fetch(PDO::FETCH_ASSOC)){
							echo "<option value=$row[id_bank]>$row[nama_bank] ($row[no_rek])</option>";
						}
					?>
				  </select>
				</div>
			  </div>
			  <div class="form-group">
				<label class="col-lg-3 control-label small">Tanggal Transfer</label>
				<div class="col-lg-7">
				  <input type="text" class="form-control input-sm" name="tanggal" value="<?php echo date("Y/m/d"); ?>" id="datepicker">
				</div>
			  </div>
			  <div class="form-group">
				<div class="col-lg-offset-3 col-lg-7">
					<input type="reset" class="btn btn-danger btn-sm" name="reset" value="Reset">
				  <input type="submit" class="btn btn-success btn-sm" name="submit" value="Konfirmasi">
				</div>
			  </div>
			</form>
		</div>
	<div class="clearfix"></div>
	</div>
  <div class="clearfix"></div>
  </div>
  <!-- end random product -->

</div>